Release of Information

Piedmont Pediatrics will typically only release what we refer to as 'standard records'. These records include a patient health summary (consisting of patient demographics, allergies, current medications, etc) notes from the most recent wellness visit (or office visit in general if wellness visit was not performed), immunization records, and growth charts.

Please note that Piedmont Pediatrics is not liable to release ANY health record that was not curated by our practice. Any health record from a specialist ,different provider, or other healthcare organization will need to be requested from that specific facility.

All record requests will be subject to a flat fee of $6.50 for  unless the retrieval method is the 'My Kid's Chart' patient portal.

If you need any other records other than the standard records, please denote them below.

 

Please be aware that by choosing 'pick-up' or 'fax', you are agreeing to incur a $6.50 flat fee for the curation and transferral of your health records. The fee will need to be paid BEFORE your request can be fulfilled. This fee will be added to your Piedmont Pediatrics patient account and can be handled in office or on your portal.

By completing this form and providing your signature, you authorizing Piedmont Pediatrics to release medical records for the above patient(s) by means of the selected release methods. The request notated on this form is effective for one (1) year from the signature date unless written revocation is submitted. Any patient under the age of eighteen (18) years of age must obtain a parent/guardian signature. Please allow 14 business days for records to be released.